Provider Demographics
NPI:1508260670
Name:KALYAN, REVATHY
Entity Type:Individual
Prefix:
First Name:REVATHY
Middle Name:
Last Name:KALYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REVATHY
Other - Middle Name:
Other - Last Name:DEVARAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1926 CRIMSON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5544
Mailing Address - Country:US
Mailing Address - Phone:248-495-3542
Mailing Address - Fax:
Practice Address - Street 1:41255 POND VIEW DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-3847
Practice Address - Country:US
Practice Address - Phone:248-495-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010107502251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics